Posted: May 31st, 2023

Decision #1: Differential Diagnosis

Case #1
A woman with personality disorder

SUBJECTIVE
Rhonda is a 32-year-old Hispanic female who presents to your office for her initial appointment. When you ask what brought her to your office, she states: “I’m at the end of my rope, I don’t know what else to do.” She then bursts into tears. Rhonda explains that she has very few friends left, and everyone seems to have “abandoned” her. Rhonda explains that she goes out of her way to help other people, and to be nice to them, but this does not seem to help.
Rhonda then stands up and begins to pace around your office at times using wild hand gestures to explain the circumstances that led up to her making the appointment with you. She describes the recent breakup with her boyfriend as traumatic and explains “when we first met, he was the best guy in the world. He treated me really well. But he just became a complete monster! Even though he broke off the relationship with me, I was glad to see it end. I hate his guts!”
Rhonda explains that her current financial situation is also precarious. She states that she recently purchased an automobile and is not certain how she is going to pay for it. She states that she had a car that was repossessed last year at that time, and that she borrowed some money from a friend to help pay for the car; the friend later turned around and accused her of theft. “It was my friend’s fault. She told me she would loan me the money and then backed out. I only took the money because she said she would loan it to me … people just can’t go back on their word like that when other people are counting on them.”
Rhonda reports that she was “always in trouble” as a kid. She states that people were always picking on her, to which she adds: “the other kids my age were just stupid. They didn’t know how to have fun.” She says “I have always been impulsive, but it’s fun. Sometimes people can be such prudes … you only go around life once, so you have to make the best of it.”

OBJECTIVE
Rhonda is currently single. She has no children. Educationally, she had completed two semesters toward her Bachelor of Arts degree in fine arts. Rhonda currently works as a waitress at a local restaurant. She has held this job for about 2 weeks. Prior to this, Rhonda worked as a housekeeper for a local hotel chain. She states that she was fired from this job because her coworkers were jealous of her and “planted” evidence of her stealing from hotel patrons. She was also arrested for cashing checks under an alias, for which she spent 120 days in jail.
Rhonda has a history of multiple incarcerations for offences ranging from larceny to possession of controlled substances to possession of an illegal firearm. She was also arrested several times for fighting and on at least one occasion, used a baseball bat to beat up a girl who she thought was trying to “set her up” with the police.

MENTAL STATUS EXAM
Rhonda is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. She reports her mood as “terrible!” Affect is labile and seems to change rapidly with the subject being discussed. Her eye contact is normal, but at times, she appears to stare at you. Rhonda is oriented to person, place, and time. She denies visual/auditory hallucinations, no overt paranoia or delusional thought processes noted. Rhonda denies any suicidal or homicidal ideation.

Assignment: Decision Tree (Due in Week 4)
For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat adult and older adult clients presenting symptoms of a mental health disorder.
Learning Objectives
Students will:
• Evaluate clients for treatment of mental health disorders
• Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
** Assigned in Week 3 and submitted in Week 4
Examine Case 1: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.
At each Decision Point, stop to complete the following:
• Decision #1: Differential Diagnosis
o Which Decision did you select?
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
• Decision #2: Treatment Plan for Psychotherapy
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
• Decision #3: Treatment Plan for Psychopharmacology
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients and their family.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO RHONDA?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Borderline Personality Disorder: Click to see options it will take you to decision point two and three.

Histrionic Personality Disorder: Click to see options it will take you to decision point two and three.

Antisocial Personality Disorder: Click to see options it will take you to decision point two and three.

All references require creditable sources, nothing less than 5 years. References require APA 7th edition http//. Please add conclusion.

_____________________________
Decision #1: Differential Diagnosis

Based on the information provided in the scenario, the diagnosis that the psychiatric/mental health nurse practitioner (PMHNP) would give to Rhonda is Borderline Personality Disorder (BPD).

Borderline Personality Disorder (BPD) is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, as well as marked impulsivity. Let’s examine the symptoms presented by Rhonda and link them to the DSM-5 criteria for BPD:

Unstable interpersonal relationships: Rhonda reports that she has very few friends left and feels that everyone has abandoned her. She also describes a traumatic breakup with her boyfriend and expresses intense anger towards him.

Emotional instability: Rhonda’s affect is labile, rapidly changing with the subject being discussed. She reports her mood as “terrible.” These fluctuations in mood are characteristic of BPD.

Impulsivity: Rhonda describes herself as impulsive and believes that it is fun. This impulsive behavior is consistent with the DSM-5 criteria for BPD.

History of self-destructive behaviors: Although not explicitly mentioned in the scenario, Rhonda’s history of multiple incarcerations, fighting, and using a baseball bat to attack someone she believed was trying to set her up with the police indicate a pattern of self-destructive behaviors often seen in individuals with BPD.

Fear of abandonment: Rhonda expresses a fear of abandonment and feels that people have abandoned her. This fear is a common characteristic of BPD.

Based on the symptoms described, Rhonda meets the criteria for Borderline Personality Disorder according to the DSM-5. This diagnosis provides a framework for understanding her difficulties with interpersonal relationships, emotional instability, impulsivity, and self-destructive behaviors.

The difference between the expected outcome of Decision #1 and the actual result is not applicable in this case as the decision was to select a diagnosis, not to implement a specific intervention. The diagnosis of Borderline Personality Disorder helps to guide subsequent treatment decisions.

References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Paris, J. (2019). The diagnosis of borderline personality disorder: problematic but better than the alternatives. Annals of Clinical Psychiatry, 31(3), 159–164. https://doi.org/10.12788/acp.0019

Perry, J. C. (2021). Borderline personality disorder: A review. Harvard Review of Psychiatry, 29(5), 279–291. https://doi.org/10.1097/HRP.0000000000000302

Decision Point Two: Treatment Plan for Psychotherapy

For the treatment of Borderline Personality Disorder, dialectical behavior therapy (DBT) is often considered the treatment of choice. DBT is a comprehensive, evidence-based therapy that combines individual therapy, skills training groups, phone coaching, and therapist consultation teams. It focuses on helping individuals with BPD regulate their emotions, develop coping skills, improve interpersonal effectiveness, and reduce self-destructive behaviors.

Decision #2: Treatment Plan for Psychotherapy

The chosen decision is to initiate Dialectical Behavior Therapy (DBT) for Rhonda.

Why did you select this Decision?
DBT has been shown to be effective in treating Borderline Personality Disorder (BPD) and is considered the treatment of choice. It combines individual therapy, skills training groups, phone coaching, and therapist consultation teams to address the core symptoms of BPD, such as emotional dysregulation, impulsivity, and unstable interpersonal relationships. DBT helps individuals learn adaptive coping skills, mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. It provides a structured and supportive therapeutic environment that can help Rhonda develop healthier ways of managing her emotions and improve her overall functioning.

Research studies have consistently demonstrated the effectiveness of DBT in reducing self-harming behaviors, suicide attempts, and improving overall quality of life in individuals with BPD. The emphasis on skills training, validation, and the therapeutic relationship in DBT aligns well with the challenges Rhonda is facing, such as her emotional instability, impulsivity, and difficulties in interpersonal relationships.

By initiating DBT, the goal is to help Rhonda develop a range of coping strategies to manage her emotions effectively, improve her interpersonal skills, and reduce impulsive and self-destructive behaviors. The skills training groups will provide her with a supportive environment to learn and practice these skills, while individual therapy sessions will address her specific concerns and challenges.

Expected Outcome: It is expected that with DBT, Rhonda will experience a reduction in her emotional instability, impulsivity, and self-destructive behaviors. She may gain a better understanding of her emotions, develop healthier coping mechanisms, and improve her interpersonal relationships. Over time, she may also experience an increase in her overall functioning and a greater sense of stability and well-being.

Difference from Expected Outcome: It is important to note that the progress and outcomes of therapy can vary for each individual. While DBT has shown promising results in treating BPD, the specific response and progress of Rhonda may be influenced by various factors, including her level of engagement in therapy, her motivation for change, and the presence of any comorbid conditions. It is essential to regularly assess and monitor Rhonda’s response to therapy to make any necessary adjustments to the treatment plan.

References:
Linehan, M. M. (2015). Dialectical behavior therapy. In J. H. Stone, M. Blouin, M. Bard, & J. E. Alleva (Eds.), Handbook of ethics in forensic psychology: Applying psychology to the courts (2nd ed., pp. 43-51). Routledge.

Rizvi, S. L., Dimeff, L. A., Skutch, J., Carroll, D., & Linehan, M. M. (2011). A pilot study of the DBT coach: An interactive mobile phone application for individuals with borderline personality disorder and substance use disorder. Behavior Therapy, 42(4), 589-600. https://doi.org/10.1016/j.beth.2011.02.003

Wagner, A. W., & Linehan, M. M. (1999). The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Journal of Traumatic Stress, 12(3), 471-479. https://doi.org/10.1023/A:1024755414938

Decision Point Three: Treatment Plan for Psychopharmacology

The chosen decision is to initiate psychopharmacological treatment with selective serotonin reuptake inhibitors (SSRIs) for Rhonda.

Why did you select this Decision?
Pharmacotherapy can be beneficial in the treatment of Borderline Personality Disorder (BPD), particularly when specific target symptoms are present. While medication alone is not considered a primary treatment for BPD, certain medications, such as SSRIs, may be used to address comorbid conditions or target specific symptoms, such as mood instability, depression, anxiety, or impulsivity.

Rhonda presents with symptoms of mood instability, emotional dysregulation, and reports her mood as “terrible.” SSRIs, which are commonly used to treat mood disorders and anxiety, may help stabilize her mood, reduce depressive symptoms, and potentially improve her overall emotional well-being. Additionally, if Rhonda experiences com

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